Home Member Services Grievances and Appeals GA-U (Disability Lifeline) Grievance and Appeal Process

GA-U (Disability Lifeline) Grievance and Appeal Process

Appeal and Complaint Process for GA-U Members

As a Community Health Plan member, you have the right to file a complaint, an appeal about a complaint resolution or a denied claim or service. If you need help, call us at 1-800-440-1561. If you are hearing or speech impaired, call TTY 1-866-816-2479 (toll-free) or local 206-613-8875.

APPOINTING A PERSONAL REPRESENTATIVE

You may choose someone to act on your behalf. This person can be anyone, including an attorney or provider. We must have written consent from you allowing this person to represent you before the person can act on your behalf. If you have questions about having an authorized representative, call us at the number listed above.

COMPLAINTS

A complaint is anything that you are not happy with except for a denied service or referral for service. If you have a complaint, you can write to us or call us at the number above. We will let you know we got your written complaint within 5 calendar days of getting it. We will write to you within 14 calendar days with an answer.

APPEALS

An appeal is when you do not agree with how we resolved your complaint or if we denied a service or a request for a service. Appeals are confidential. You may ask at any time during the appeal to look at your file and medical records and we will send a copy to you. You may also ask for a copy of the benefit provision, guideline, protocol or other information about how the appeal decision was made.

HOW TO FILE AN APPEAL OR COMPLAINT

You can file a complaint or appeal in writing, in person, or over the phone by calling us at the number listed above.

Mail your appeal or complaint to:

Community Health Plan
Attn: Appeals Department
720 Olive Way, Suite 300
Seattle, WA 98101
Fax: (206) 613-8983

Your appeal must include your name, address, phone number, your Health Plan’s I.D. number, the nature of the complaint, and why you are asking for the appeal. You can send anything with your appeal that will help your case.

EXPEDITED (RUSH) APPEAL

If you or your doctor(s) feel that not getting care right away could cause an emergency or put your life in danger, you can ask for a “rush” or "expedited" appeal. Your doctor will speak with our Medical Director or any other person working on your case. Our Medical Director will decide if your case is a rush appeal. The rush appeal decision will happen as soon as possible but not more than 72 hours from the time we get your request. We will call you or your doctor to let you know we got your request. We will also send a letter within 72 hours from the time we got your request. You may file a complaint if we do not process your rush appeal within 72 hours from the time we got it.

If your request for a rush appeal is denied, your appeal will be answered within 14 days. If not, we will write to you and tell you why we need more time. Our decision will not take longer than 30 days from the date we got your request without your signed consent.

Note: The rush appeal right and related timeframes apply to the whole appeal process.

STANDARD APPEAL

You must file your standard appeal within 180 calendar days from the date of a denial or complaint resolution

If Community Health Plan tells you we are reducing a service you are currently getting, and you want to keep getting the service during the appeal, you may ask us to pay for those services until one of the following takes place first:
•You use up the number of visits or days approved from the original request.
•The appeal is decided.

Note: If the appeal decision is not in your favor, you will have to pay for the cost of the services you got.

We will let you know we got your appeal within 5 calendar days of getting it. We will look at your case and make a decision. We will have an answer within 14 calendar days of getting your appeal. If not, we will write to you and tell you why we need more time. Our decision will not take longer than 30 calendar days from the date we got your request without your written consent.

If you do not agree with our decision on your first level or rush appeal, you may ask for a second level appeal.

SECOND LEVEL APPEAL

To file a second level appeal, you can write or call us at 1-800-440-1561. If you are hearing or speech impaired, call TTY 1-866-816-2479 (toll-free) or local 206-613-8875. Mail your written second level appeal to the address listed above.

We will let you know we got your appeal within 5 calendar days of getting it. During the second level review, Community Health Plan will make sure the person who denied your appeal the first time does not review it the second time. Community Health Plan will use their Second Level Grievance Committee to review your appeal.

The Grievance Committee is made up of people who were not part of the decision to deny your request the first time. They will review your case and all information you submit. They will make a decision. If you want to come to their meeting or join by phone, call or write us as soon as possible after getting the letter that says we got your appeal. You can ask anyone to be part of the meeting if they can help your case. If someone else is coming in your place, we must have your written consent for them to speak for you.

We will send you an answer within 14 calendar days of getting your appeal. If not, we will write to you and tell you why we need more time. Our decision will not take longer than 30 calendar days from the date we got your request without your written consent.

If you do not agree with the Second Level Grievance Committee’s decision, you have the right to ask that an Independent Review Organization (IRO) review your case.

INDEPENDENT REVIEW

You must ask for the IRO review within 180 calendar days from the date of the committee decision. We can help you file an IRO. If you need help call the number listed above. Send your written request for review of your appeal by an IRO to the address listed above.

The IRO that reviews your case is not a part of Community Health Plan. When the IRO makes a decision, they will contact you. They will tell you their decision and the reason for it.

If your health requires that a decision be made quickly, you can ask the review to be “rushed” or expedited. In this case you will get a decision in 72 hours.

EXPEDITED REVIEW BY AN IRO

You may request a rush review by an IRO. If Community Health Plan’s Medical Director or your provider thinks the standard IRO timelines could endanger your life or health the IRO must rush its review process and make a decision within 72 hours from the time we got the request.

If Community Health Plan denies your request for a rush review by an IRO, the IRO will use the same timeframe for standard reviews. We will speak to you about the notice of the denial as fast as we can. We will also send a written notice within 72 hours from the time we got the request.

If you do not agree with the IRO’s decision, you may ask the State of Washington Department of Social and Health Services (DSHS) to review your case at a Hearing.

DSHS HEARING

You must do all levels of the Community Health Plan appeal and the IRO process before asking for a hearing. You can ask for a hearing by:
•Calling your local Community Service Office (CSO) hearing coordinator; or
•Calling the Office of Administrative Hearings (OAH) at 1-800-583-8271; or
•Writing to:
    Office of Administrative Hearings
    PO Box 42489
    Olympia, WA 98504-2489

DSHS needs to know what was denied, when, and why. You can have someone speak for you. If you ask, the CSO or OAH can give you a list of people that may help you with your case.

You must ask for a DSHS Hearing within 90 calendar days of the date on which Community Health Plan denied your appeal.

If your health requires that a decision be made quickly, you can ask for the hearing to be “rushed” or expedited. In this case you can receive a decision in 72 hours.

In all levels of the appeal, IRO review, and DSHS Hearing, all decisions related to your appeal are made by persons not involved in the initial determination. All decision makers have credentials for the level of the decision they make.

If you have any questions about any procedure or process in this document, contact us at 1-800-440-1561. If you are hearing impaired, please call TTY 1-866-816-2479 (toll-free) or local 206-613-8875.